2019B15 Describe the anatomy and relations of the right internal jugular vein relevant to performing
central venous cannulation.

Location

In the anterior triangle

·  Anterior midline

·  Anterior border of sternocleidomastoid

·  Inferior angle of the mandible

Origin

·  Confluence of R sigmoid sinus + R inferior petrosal sinus, at the jugular foramen

Passage

·  Passes vertically down the neck

·  Within the carotid sheath

Termination

·  R internal jugular vein + R subclavian vein -> R brachiocephalic vein

·  Note direct continuation to SVC and right atrium, hence right internal jugular preferred to left

Relation to internal carotid artery

·  At C2: posterior

·  At C3: posterolateral

·  From C4: lateral

·  (note may appear posterior in the lower neck if ultrasound applied radially rather than antero-posterior)

Relation to other major neck structures

·  Anterior: sternocleidomastoid

·  Posterior: lateral mass of C1, anterior and middle scalenes, pleura of lung apices

·  Medial: thyroid, trachea, oesophagus

·  Lateral: sternocleidomastoid, fascia, skin

Landmark

·  Trendelenburg (prevent air embolus)

·  Head rotated contralaterally

·  Palpate carotid artery medially

·  Enter skin in the middle of the triangle formed by the two heads of SCM and clavicle (~C6 level)

·  Angle needle 30 degrees to the skin

·  Aim at ipsilateral nipple

Ultrasound

·  Gold standard

·  Same prep + position

·  Probe best positioned for AP view rather than radial view to avoid carotid puncture

·  Identify vessels by shape, pulsatility, compressibility, direction of blood flow

Damage to surrounds

·  Common carotid artery or internal carotid artery -> bleeding, stroke

·  Vagus nerve

·  SNS nerve -> Horner’s syndrome

·  Pleura -> pneumothorax

·  Trachea, oesophagus, thyroid

·  Thoracic duct -> chylothorax

Other

·  Arrythmia (wire in RV) -> myocardial ischaemia if susceptible

·  Venous air embolism

·  Bleeding

·  Infection